Temporary Diverting End-Colostomy in Critically Ill Children with Severe Perianal Wound Infection.

ABSTRACT: Broad and deep perianal wounds are challenging in both adult and pediatric ICUs. These wounds, if contaminated with gastrointestinal flora, can cause invasive sepsis and death, and recovery can be prolonged. Controlling the source of infection without diverting stool from the perianal region is complicated. The option of protective colostomy is not well-known among pediatric critical care specialists, but it can help patients survive extremely complicated critical care management. These authors present three critically ill children who required temporary protective colostomy for perianal wounds because of various clinical conditions. Two patients were treated for meningococcemia, and the other had a total artificial heart implantation for dilated cardiomyopathy. There was extensive and profound tissue loss in the perianal region in the patients with meningococcemia, and the patient with cardiomyopathy had a large pressure injury. Timely, transient, protective colostomy was beneficial in these cases and facilitated the recovery of the perianal wounds. Temporary diverting colostomy should be considered as early as possible to prevent fecal transmission and accelerate perianal wound healing in children unresponsive to local debridement and critical care.

Extraperitoneal colostomy in robotic surgery for rectal cancer using a tip-up fenestrated grasper.

INTRODUCTION: Although extraperitoneal colostomy could reduce the risk for parastomal hernia formation, it is often technically demanding to dissect the extraperitoneal route laparoscopically. Here, we demonstrate our original surgical technique for extraperitoneal tunneling using a robotic instrument. MATERIALS AND SURGICAL TECHNIQUE: After total mesorectal excision (TME) and before specimen retrieval, the edge of the outer leaf of the parietal peritoneum was elevated by the grasper in the left hand and the tip-up fenestrated grasper (Tip-Up) in the right hand. The extraperitoneal tissue was opened using the scissor forceps (right hand). Then, extraperitoneal tunneling (inner tunnel) was performed using a Tip-Up with a width of approximately 4 cm that could reach adjacent to the lateral border of the abdominal rectus muscle. A round incision was made at a preoperatively marked site on the skin. The anterior rectal sheath was cut in a cruciate fashion. The abdominal rectus muscle was split, and then the posterior rectus sheath was cut longitudinally not just below the stoma marking site but also at a slant on the lateral side. The peritoneum was dissected with care to avoid opening the peritoneum. The outer side of the tunnel was broken through to the inner tunnel using an easy blunt dissection with two fingers. Kelly forceps were introduced through the extraperitoneal tunnel along with the fingers, and the stump of the sigmoid colon was grasped and exteriorized through this tunnel. DISCUSSION: Robotic retroperitoneal tunneling using a Tip-Up is easy and useful for preventing parastomal hernia.

Outcomes of stapler repair with anastomosis for stoma prolapse.

PURPOSE: The published data on the outcomes of an operative repair for stoma prolapse are limited. This study aimed to clarify the long-term outcomes of stapler repair with anastomosis for stoma prolapse. METHODS: Twenty-four patients (15 men, median age 64 years, range 33-88 years) undergoing 25 stapler repairs with anastomosis were prospectively registered, and their medical records were retrospectively reviewed. RESULTS: The median length of prolapse was 10 cm (range 5-22). Stoma prolapse repair was performed by means of 16 loop colostomies, four end colostomies, three loop ileostomies, and one end ileostomy. A stapler was used 4.6 times on average (range 4-8). The average operative time and bleeding were 40.8 (range 15-75) min and 40 (range 0-214) mL, respectively. No mortality and morbidity were observed after surgery. A recurrence of stoma prolapse was reported in only one of 25 repairs (4%) at the proximal limb of loop ileostomy during a median follow-up period of 1 year (range 1-120 months). However, a new stoma prolapsed in one untreated limb of loop stoma. CONCLUSIONS: Stapler repair with anastomosis is a safe and minimally invasive treatment option for stoma prolapse with a low recurrence. However, the effectiveness of reparing stoma prolapse on the proximal limb of loop ileostomy might be limited.

Mini-invasive Surgery and Parastomal Hernia: Higher Frequency and No Prophylactic Mesh Effect.

AIM: Parastomal hernia (PSH) is very common. Recent reports suggest increased frequency after laparoscopic stoma formation compared with open surgery. A retrospective chart review was designed to appraise the outcomes regarding PSH in open and in laparoscopic procedures. MATERIALS AND METHODS: All patients operated by rectal resection and planned end-colostomy in the period from 2004 to 2018 were reviewed. A total of 70 open and 101 laparoscopic operations were identified. A modified retromuscular mesh application through the trephine was used for the prevention of PSH in 42% of patients in the laparoscopic group. RESULTS: The median follow-up was 58 (1 to 167) months in the open group and 43 (0 to 153) months in the laparoscopic group. Patient characteristics were evenly distributed between the groups, except for more male patients and higher American Society of Anesthesiologists Score as well as higher rates of patients with neoadjuvant treatment and mesh prophylaxis, in the laparoscopic group. Clinical PSH occurrences were 2 (3%) in the open group and 18 (18%) in the laparoscopic group (P=0.00). Propensity-weighted analysis estimates increased odds ratio (OR) for PSH in the laparoscopic group [OR=11.8; 95% confidence interval (CI): 1.4-96.6]. PSH repair rates were 0 in the open group and 6/18 (33%) in the laparoscopic group. Mesh prophylaxis in the laparoscopic group did not influence PSH outcome (OR=1.4; 95% CI: 0.5-4.0). Computed tomography scans were assessable in 48 and 66 patients, with median follow-up timepoints of 42 and 30 months in the open and laparoscopic groups, respectively, and 8 (18%) and 21 patients (32%) were diagnosed with PSH. Computed tomography assessment implied an increased risk for PSH in laparoscopy (OR=3.5; 95% CI: 1.1-11.9). Aggregate of chart and computed tomography occurrence of PSH showed an equivalent hazard (OR=3.2; 95% CI: 1.1-9.5). INTERPRETATIONS: Laparoscopic operations with stoma formation seem to have an increased rate of PSH in comparison with open operations and the results support previous claims. Retromuscular keyhole mesh placement may not be the ideal method of PSH prevention in laparoscopic stoma formation.

Feasibility and Efficiency of Sutureless End Enterostomy by Means of a 3D-Printed Device in a Porcine Model.

Objective. The aim of this study is to present a 3-dimensional (3D)-printed device to simply perform abdominal enterostomy and colostomy. Summary Background Data. Enterostomy and colostomy are frequently performed during abdominal surgery. 3D-printed devices may permit the creation of enterostomy easily. Methods. The device was designed by means of a CAD (computer-aided design) software, Rhinoceros 6 by MC Neel, and manufactured using 3D printers, Factory 2.0 by Omni 3D and Raise 3D N2 Dual Plus by Raise 3D. Colostomy was scheduled on a human cadaver and on 6 Pietrain pigs to test the device and the surgical technique. Results. The test on the cadaver showed that the application of the device was easy. Test on porcine models confirmed that the application of the device was also easy on the living model. The average duration of the surgical procedure was 32 minutes (25-40 minutes). For the female pigs, return to full oral diet and recovery of a normal bowel function was observed at postoperative day 2. The device fell by itself on average on the third day. Until day 10, when euthanasia was practiced, the stoma mucosa had a good coloration indicating a perfect viability of tissues. No complications were observed. Conclusions. This is the first study that describes the use of a 3D-printed device in abdominal surgery. End-type colostomy using a 3D-printed device can be safely and easily performed in an experimental porcine model, without postoperative complications. Further studies are needed to evaluate its utility in the clinical setting.

Do North American colorectal surgeons use mesh to prevent parastomal hernia? A survey of current attitudes and practice

Background: The use of prophylactic mesh in end colostomy procedures has been shown to reduce the rate of parastomal hernia. However, the degree to which the practice has been adopted clinically remains unknown. We conducted a study to evaluate the current opinions and practice patterns of Canadian and US colorectal surgeons with regard to the use of prophylactic mesh in end colostomy. Methods: Between May and July 2017, we conducted an internet-based survey of colorectal surgeons in Canada and the United States (selected at random). Using a questionnaire designed and tested for this study, we assessed the rate of mesh use, types of mesh and placement techniques, and perceived barriers and facilitators associated with the practice. Results: Forty-eight (51.6%) of 93 invited Canadian surgeons and 253 (16.6%) of 1521 invited US surgeons responded (overall response rate 18.6%). Of the 301 respondents, 32 (10.6%) were currently using mesh, 32 (10.6%) had previously used mesh, and 237 (78.7%) had never used mesh. Of 29 respondents currently using mesh, 12 (41.4%) used it only in selected patients; the majority used a sublay technique (20 [69.0%]) and biologic mesh (17 [58.6%]). Most respondents agreed that parastomal hernias are common and negatively affect quality of life; however, there remained concerns about evidence quality and the perceived risk associated with mesh among those who had never or had previously used mesh. Conclusion: Prophylactic mesh placement remains relatively uncommon; when used, biologic mesh was the most common type. Many surgeons were not convinced of the safety or efficacy of prophylactic mesh placement.

Contexte: Il a été démontré que la pose d'un treillis prophylactique durant une colostomie terminale réduit le risque de hernie parastomale. On ignore toutefois à quel point cette pratique a été adoptée en contexte clinique. Nous avons mené une étude pour connaître l'opinion et les habitudes des chirurgiens colorectaux canadiens et américains quant à cette intervention. Méthodes: De mai à juillet 2017, nous avons mené un sondage en ligne auprès de chirurgiens colorectaux canadiens et américains sélectionnés aléatoirement. À l'aide d'un questionnaire conçu et validé pour cette étude, nous avons évalué le taux de pose de treillis, le type de treillis et la technique utilisé, ainsi que les facteurs facilitant ou limitant l'intervention. Résultats: Au total, 48 des 93 chirurgiens canadiens (51,6 %) et 253 des 1521 chirurgiens américains (16,6 %) approchés ont répondu au sondage (taux de réponse global : 18,6 %). Sur les 301 répondants, 32 (10,6 %) ont dit qu'ils installent actuellement des treillis, 32 (10,6 %) ont dit en avoir installé, et 237 (78,7 %) ont dit n'en avoir jamais installé. Parmi 29 répondants posant actuellement des treillis, 12 (41,4 %) ont déclaré y avoir recours pour certains patients seulement; la majorité pose les treillis dans l'espace prépéritonéal (20 [69,0 %]) et se sert de treillis biologiques (17 [58,6 %]). La plupart des répondants s'entendaient pour dire que les hernies parastomales sont courantes et ont des répercussions négatives sur la qualité de vie des patients; cependant, les chirurgiens n'ayant jamais installé de treillis ou en ayant seulement installé par le passé se sont dits préoccupés par la qualité des données et les risques perçus associés aux treillis. Conclusion: La pose d'un treillis à des fins prophylactiques demeure relativement rare. Les treillis biologiques étaient les plus fréquemment utilisés par les répondants. Bon nombre des chirurgiens questionnés n'étaient pas convaincus de l'innocuité ou de l'efficacité de l'intervention.

Innovative appliance for colostomy patients: an interventional prospective pilot study.

BACKGROUND: The control of body waste emptying is a constant research topic in stoma care. The aim of this pilot study was to assess the efficacy and safety of an innovative colostomy appliance. METHODS: An interventional prospective non-comparative pilot study was conducted in seven French centers. The study device is a new type of two-piece appliance including a base plate and a "capsule cap" (CC) composed of a capsule cover and a folded collecting bag. The device gently seals the stoma to provide stoma output control. When the bowel movement pressure increases the patient may control the deployment of the folded bag and collect stools. Patients with left-sided colostomy all using a flat appliance, were enrolled in a 2-week trial. Outcome measures were type of CC removal and peristomal fecal leaks while wearing the device. RESULTS: Of 30 patients (females 66.7%), with left-sided colostomy (permanent 76.7%), 23 (76.7%) completed the 2-week trial. A total of 472 CC changes were analyzed. EFFICACY: of 404 (85.5%) CC changes reported in diaries, 302 (74.8%) were linked with stool and/or gas. In 244 (60.3%) changes, the patient controlled stoma bag deployment and it occurred with bowel emptying 301 (74.5%) times. No leaks around the appliance were observed in 400 (85.3%) changes. SAFETY: no serious adverse event occurred. Peristomal skin was not modified during the trial. CONCLUSIONS: In the short term this new device has provided an increased control over bowel emptying at no risk in half of the trial population suggesting that an alternative approach to bag wearing is achievable.

Prevention of parastomal hernia using mesh in patients undergoing rectum extirpation.

INTRODUCTION: Developing a parastomal hernia can lead to emergency surgery and cause discomfort. Placing a pro-phylactic mesh around the ostomy may potentially prevent hernias from developing. Randomised clinical trials and reviews have reported contradictory results from this prophylactic procedure with different rates of hernias and success. This descriptive cohort study aimed to investigate the rate of parastomal hernia after applying prophylactic mesh in patients undergoing surgery for rectal cancer. METHODS: In the period from 2010 to 2016, we included 133 patients who had a permanent colostomy with prophylactic mesh placement due to rectal cancer. The patients were seen in the ostomy ambulatory at least three times annually, and bulges and hernias were registered by a trained nurse. Computed tomography was used for verification of parastomal hernia. Data were registered retrospectively from patient files. RESULTS: After a median follow-up of 22 months, 24% of patients developed a parastomal hernia. Development of parastomal bulge without a subsequent hernia diagnosis was seen in 21%. The one-year rate of parastomal hernia was 9.7%. CONCLUSIONS: This cohort study supports the thesis of a low short-time rate of parastomal hernia in patients who had a prophylactic mesh placed during the ostomy formation and indicates that the rate of hernia increases over time after the first post-operative year. FUNDING: none. TRIAL REGISTRATION: not relevant.

Stoma rods in abdominal surgery: a systematic review and metaanalyses.

BACKGROUND: Stoma rods are used traditionally to prevent retraction of loop stomas into the abdominal cavity. However, there is very little evidence to support or refute their use. The aim of the present systematic review and metaanalysis was to assess the current data on stoma rods in loop stomas. The primary outcomes were stoma necrosis and stoma retraction. METHODS: A systematic review and metaanalyses were conducted using the preferred reporting items for systematic reviews and metaanalysis guidelines (PRISMA). The study protocol was registered prospectively on PROSPERO. An electronic search was performed by two reviewers independently using predefined search strategy and Medline. Bibliographies of selected studies were screened for additional references. RevMan was used to generate forest plots and calculate odds ratios and 95% confidence intervals (CIs). RESULTS: In total, five studies were identified that met inclusion criteria, including four randomized controlled trials. Three studies examined only ileostomies, while one included both colostomies and ileostomies, and one only examined colostomies. In total, 561 patients underwent a stoma with a rod compared to 443 without. There was a higher rate of dermatitis (rod 29.86% vs no rod 16% OR 2.65; 95% CI 1.79-3.93) and stoma necrosis (rod 7% vs no rod 1.15% OR 5.58; 95% CI 1.85-16.84) in the rod group, but there was no significant difference in stoma retraction (rod 2.28% vs no rod 3.45%; OR 0.7; 95% CI 0.32-1.54). CONCLUSIONS: Stoma rods do not reduce the incidence of stoma retraction and instead lead to increased rates of dermatitis and stoma necrosis.

Use of Prophylactic Mesh When Creating a Colostomy Does Not Prevent Parastomal Hernia: A Randomized Controlled Trial-STOMAMESH.

OBJECTIVE: The aim of this study was to determine whether parastomal hernia (PSH) rate can be reduced by using synthetic mesh in the sublay position when constructing permanent end colostomy. The secondary aim was to investigate possible side-effects of the mesh. BACKGROUND: Prevention of PSH is important as it often causes discomfort and leakage from stoma dressing. Different methods of prevention have been tried, including several mesh techniques. The incidence of PSH is high; up to 78%. METHODS: Randomized controlled double-blinded multicenter trial. Patients undergoing open colorectal surgery, including creation of a permanent end colostomy, were randomized into 2 groups, with and without mesh. A lightweight polypropylene mesh was placed around the colostomy in the sublay position. Follow up after 1 month and 1 year. Computerized tomography and clinical examination were used to detect PSH at the 1-year follow up. Data were analyzed on an intention-to-treat basis. RESULTS: After 1 year, 211 of 232 patients underwent clinical examination and 198 radiologic assessments. Operation time was 36 minutes longer in the mesh arm. No difference in rate of PSH was revealed in the analyses of clinical (P = 0.866) and radiologic (P = 0.748) data. There was no significant difference in perioperative complications. CONCLUSIONS: The use of reinforcing mesh does not alter the rate of PSH. No difference in complication rate was seen between the 2 arms. Based on these results, the prophylactic use of mesh to prevent PSH cannot be recommended.

Evaluation of a one-piece soft convex ostomy appliance: a prospective, multicentre, open-label pilot study.

Leakage of stomal effluent is considered by people living with a stoma to be the key factor that negatively impacts their quality of life (QoL). This non-randomised pilot study evaluated the performance of a new stoma appliance, Flexima® Active O Convex in 40 ostomy patients with a flat, flush or slightly retracted stoma over a 14-day period. Leakage was reported for the wear time of each pouch by the patients. On 79% of occasions, the patient reported no leakage under the skin protector. The appliance was very well tolerated and the condition of the patients' peristomal skin was maintained throughout the study. The performance was rated as 'good' or 'very good' by most of the patients. The results of this study have shown that the design of this one-piece soft convex appliance can prevent leakage and protect peristomal skin by providing a safe seal around the stoma. It was also reported as being flexible and comfortable to wear.

Novel Pouching Techniques for the Neonate With Fecal Ostomies.

BACKGROUND: Neonatal ostomy management is challenging even under the best circumstances. When complex circumstances are encountered, creative pouching techniques must be employed. CASES: This article describes management of 5 neonates with problematic ostomies. CONCLUSION: Maintaining a neonatal pouch seal at times requires using modified adult pouching products; however, caution should always be used due to the fragility of this patient population.

Síndrome McKittrick-Wheelock: raro, pero potencialmente letal / McKittrick-Wheelock syndrome: unusual, but potentially lethal

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A prospective randomized controlled trial comparing early postoperative complications in patients undergoing loop colostomy with and without a stoma rod.

AIM: A stoma rod or bridge has been traditionally placed under the bowel loop while constructing a loop colostomy. This is believed to prevent stomal retraction and provide better faecal diversion. However, the rod can cause complications such as mucosal congestion, oedema and necrosis. This single-centre prospective randomized controlled trial compared outcomes after creation of loop colostomy with and without a supporting stoma rod. The primary outcome studied was stoma retraction rate; other stoma-related complications were studied as secondary outcomes. METHOD: One hundred and fifty-one patients were randomly allotted to one of two arms, colostomy with or without a supporting rod. Postoperative complications such as retraction, mucocutaneous separation, congestion and re-exploration for stoma-related complications were recorded. RESULTS: There was no difference in the stoma retraction rate between the two arms (8.1% in the rod arm and 6.6% in the no-rod arm; P = 0.719). Stomal necrosis (10.7% vs 1.3%; P = 0.018), oedema (23% vs 3.9%; P = 0.001), congestion (20.3% vs 2.6%; P = 0.001) and re-admission rates (8.5% vs 0%; P = 0.027) were significantly increased in the arm randomized to the rod. CONCLUSION: The stoma rod does not prevent stomal retraction. However, complication rates are significantly higher when a stoma rod is used. Routine use of a stoma rod for construction of loop colostomy can be avoided.

Prophylactic meshes in the abdominal wall.

BACKGROUND: There is a high incidence of incisional hernias in specific high-risk patient populations. For these patients, the prophylactic placement of mesh during closure of the abdominal wall incision has been investigated in several prospective studies. OBJECTIVE: This article aims to summarize and synthetize the currently available evidence on prophylactic meshes in a narrative review. MATERIALS AND METHODS: Systematic reviews were performed on the use of prophylactic meshes in different indications: midline laparotomies, stoma reversal wounds, and permanent stoma. RESULTS: High-quality data from randomized trials shows that prophylactic synthetic non-absorbable mesh implantation is safe and effective, both in prevention of incisional hernias after midline laparotomies and during construction of an elective end colostomy. It should be considered in patients with a high risk for incisional hernia development, such as those receiving open abdominal aortic aneurysm, obesity, or colorectal cancer surgery. It is strongly recommended for construction of an elective permanent end colostomy. For midline laparotomies, both the retromuscular and onlay positions of a prophylactic mesh seem equally effective and safe. For parastomal hernia prevention, only the retromuscular prophylactic mesh and its use for end colostomies has been proven to be effective and safe. No data support the choice of a biological mesh or a synthetic absorbable mesh over a non-absorbable synthetic mesh, even in clean-contaminated surgical procedures. No data yet support the standard use of prophylactic mesh when closing the wound during closure of a temporary stoma. CONCLUSION: Prophylactic mesh implantation should be standard of care during construction of an elective end colostomy and will become standard of care for midline laparotomies in patients at a high risk of incisional hernias.

[Development of Magnetic Anastomosis Device for Colostomy].

Introduction of a new magnetic anastomosis device for colostomy including its design and operaging principal. The anastomosis device is composed of magnetic base and anastomosis ring. It is convenient for colon and abdominal subcutaneous tissue going together through the magnetic attraction. The colostomy completes with magnetic compression anastomosis. The device has the advantage of making operation easer, reducing the operation steps and can better solve the colostomy ischemic necrosis, colostomy retraction, colostomy joint complications of skin mucous membrane and the skin diease around the colostomy. Patients can real y benefit from this device.

Evaluation of a new ostomy mouldable seal: an international product evaluation.

A new mouldable seal, Brava® Protective Seal, was evaluated by patients on aspects related to residue, durability, and preference. A total of 135 patients from four countries participated (Denmark, Germany, Japan and the USA) and the new product was compared to the patients' usual pouching systems. Less residue and easier skin cleansing was observed, which may benefit patient quality of life. The possible benefits of less residue for peristomal skin health need further investigation.